Pneumodilation versus Per-Oral Endoscopic Myotomy in Achalasia patients with recurrent symptoms after Laparoscopic Heller Myotomy

Summary POEMA-2 trial

Idiopathic achalasia is a rare motility disorder of the oesophagus with an annual incidence rate of 1

per 100,000 persons. Achalasia i caused by progressive destruction and degeneration of the neurons

in the myenteric plexus. This leads to subsequent retention of food and saliva in the oesophagus,

resulting in the typical symptoms of achalasia such as dysphagia, chest pain, regurgitation of

undigested food and weight loss. On the long term, incomplete oesophageal emptying and reflux

result in an increased risk for development of squamous cell carcinoma of the oesophagus. The cause

of the neuronal degeneration found in achalasia is unknown.


Treatment procedures include: endoscopic pneumodilations (PD) and laparoscopic Heller myotomy.

Unfortunately, some patients experience recurrent or persistent symptoms after pneumodilations

and Heller myotomy. Patients with recurrent symptoms after undergoing a laparoscopic Heller

myotomy are usually treated with pneumodilation . However, the success rates of pneumodilation

after laparscopic Heller myotomy are only between 50-67% leaving a substantial proportion of these

patients with recurrent symptoms.


Recently, a new procedure has been introduced, the per-oral endoscopic myotomy. During per-oral

endoscopic myotomy the circular muscle layers of the lower oesophageal sphincter are cut similar

to the Heller myotomy, but the approach is through the wall of the esophagus with the endoscope

instead of laparoscopically.


This study compares the efficacy of POEM to the efficacy of pneumodilation for the treatment of

recurrent symptoms in patients with idiopathic achalasia that previously underwent Heller myotomy.

This study is a multicenter randomized clinical trial, including adult patient with persistent or

recurrent symptomatic idiopathic achalasia after Heller myotomy.

We hypothesize that per-oral endoscopic myotomy has a higher long-term efficacy than pneumodilation in treatment of patients with recurrent symptoms after Heller myotomy

3 months, 1, 2 and 5 years

per-oral endoscopic myotomy (intervention)